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Cystoscopy for uncomplicated lower urinary tract symptoms

Cystoscopy for uncomplicated lower urinary tract symptoms

Best Practice Guidance

How up to date is this information?

Published January 2020 | Last reviewed September 2024

Using this guidance

The guidance set out here was reviewed extensively in the Autumn of 2024. There are no plans for any further reviews.

Medicine is constantly evolving and over time it is inevitable that the evidence base will change. Please use your own judgement and/or other sources of clinical guidance alongside the information set out here.

Please note this guidance is a recommendation and it should be used in the context of the overall care pathway and when all alternative interventions that may be available locally have been undertaken.

Summary

Cystoscopy is a diagnostic procedure used to examine the lining of the bladder and urethra. Either a rigid or flexible endoscope may be used, under general or local anaesthesia, respectively. Rigid cystoscopy is undertaken when flexible cystoscopy offers insufficiently clear views, or when biopsy is indicated.

Cystoscopy can cause temporary discomfort, occasionally pain and haematuria and is associated with a small risk of infection.

In the context of male lower urinary tract symptoms (LUTS), cystoscopy may offer indirect evidence regarding an underlying cause (commonly prostatic enlargement, for example).

 

This guidance applies to male adults aged 19 years and over.

 

Recommendation

Assessment of men with LUTS should focus initially on a thorough history and examination, complemented by use of a frequency – volume chart, urine dipstick analysis and International Prostate Symptom Score where appropriate. This assessment may be initiated in primary care settings.

Specialist assessment should also incorporate a measurement of flow rate and post void residual volume.

 

Cystoscopy should be offered to men with LUTS only when clinically indicated, for example, in the presence of the following features from their history:

  • Recurrent infection
  • Sterile pyuria
  • Haematuria
  • Profound symptoms

Additional contextual information may also inform clinical decision-making around the use of cystoscopy in men with LUTS. Such factors might include, but not be limited to:

  • Smoking history
  • Travel or occupational history suggesting a high risk of malignancy
  • Previous surgery.

Other adjunct investigations may become necessary in specific circumstances and are dealt with in the NICE guideline. It may be reasonable to undertake flexible cystoscopy before doing some urological surgical interventions.

Rationale for recommendation

In the context of male lower urinary tract symptoms (LUTS), cystoscopy may offer indirect evidence regarding an underlying cause (commonly prostatic enlargement, for example). However, no evidence was discovered in preparing NICE guideline CG97 to suggest any benefit, in terms of outcome, related to performing cystoscopy in men with uncomplicated LUTS (i.e. LUTS with no clinical evidence of underlying bladder pathology). The consensus opinion of the NICE guideline development group therefore aligned with the position that unless likely to uncover other pathology, cystoscopy should not be performed in men presenting with LUTS.

The European Association of Urology guideline on the management of nonneurogenic male LUTS summarises evidence demonstrating a lack of clear correlation between findings on cystoscopy and findings on investigations into bladder function (urodynamic assessment).

Patient information

There is no specific EBI patient guidance for this intervention.

However, we recommend using the BRAN principles (Benfits, Risks, Alternatives and do Nothing) when speaking with patients about this.

Further information on patient involvement in EBI can be found on the EBI for patients section.

Make the most of your appointment using BRAN

2020

Coding

WHEN LEFT(Primary_Spell_Procedure,4) in ('M455','M458','M459')
AND NOT ( Any_Spell_Diagnosis LIKE '%F171%' 
OR Any_Spell_Diagnosis LIKE '%N390%' 
OR Any_Spell_Diagnosis LIKE '%R31%' 
OR Any_Spell_Diagnosis LIKE '%R398%')
AND Any_Spell_Procedure NOT LIKE '%M45[1-4]%'
-- Gender is Male
AND Sex=1 
-- Age between 19 and 120
AND ISNULL(APCS.Age_At_Start_of_Spell_SUS,APCS.Der_Age_at_CDS_Activity_Date) between 19 AND 120 
-- Only Elective Activity
AND APCS.Admission_Method not like ('2%') 
THEN '2H_cystoscopy_UTI'
Exclusions
WHERE 1=1
-- Cancer Diagnosis Exclusion
AND (Any_Spell_Diagnosis not like '%C[0-9][0-9]%' 
AND Any_Spell_Diagnosis not like '%D0%' 
AND Any_Spell_Diagnosis not like '%D3[789]%' 
AND Any_Spell_Diagnosis not like '%D4[012345678]%' 
OR Any_Spell_Diagnosis IS NULL)
-- Private Appointment Exclusion
AND apcs.Administrative_Category<>'02'

References

  1. NICE Clinical guideline (2010) Lower urinary tract symptoms in men: management [CG97] .
  2. European Association of Urology. Management of non-neurogenic male LUTS
  3. Shoukry, I., et al. Role of uroflowmetry in the assessment of lower urinary tract obstruction in adult males. Br J Urol, 1975. 47: 559 DOI: 10.1111/j.1464-410x.1975.tb06261.x
  4. Anikwe, R.M. Correlations between clinical findings and urinary flow rate in benign prostatic hypertrophy. Int Surg, 1976. 61: 39
  5. el Din, K.E., et al. The correlation between bladder outlet obstruction and lower urinary tract symptoms as measured by the international prostate symptom score. J Urol, 1996. 156: 102 DOI: 10.1097/00005392-199603000-00061
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